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Pelvic Prolapse and Lower Urinary Tract Symptoms

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1 Pelvic Prolapse and Lower Urinary Tract Symptoms
Hann-Chorng Kuo Department of Urology Buddhist Tzu Chi General Hospital

2 Vaginal Prolapse Anterior vaginal prolapse – cystocele, urethral hypermobility, cystourethrocele Middle vaginal prolapse – apical prolapse, enterocele (bowel herniation), uterine prolpase, vault prolapse Posterior vaginal prolapse – rectocele (rectal herniation)

3 Anatomical classification of Pelvic prolapse

4 Prevalence of pelvic prolapse
11.1% of all women by age 80 years Comprise 16.3% of the indications for hysterectomy Patients often initially present to urologists with complaint of stress urinary incontinence

5 Vaginal support Vaginal vault – supported by cardinal and uterosacral ligaments Uterine support – broad ligaments attached to lateral pelvic wall Mid vagina – supported by lateral attachments to pubococcygeal muscles Distal vagina – embedded in connective tissue of perineal membrane and attached to urogenital diaphragm structures

6 The vaginal support


8 retroverted uterus: 1st sign attenuation, stretching
                                                                                                retroverted uterus: 1st sign attenuation, stretching or Breakage ??

9 ut cx 130o b LP sp u r v


11 Sagittal view Coronal view

12 Pathophysiology of cystocele
Weakened pubocervical fascia at the medial edge of the levator muscle Detachment of lateral vaginal wall from the pelvic side wall at the white line of arcus tendineus fascia

13 Pelvic organ support & prolapse


15 Classification of cystocele
Anatomical grade: Gr I: Bladder descent toward introitus with straining Gr II Bladder to introitus with straining Gr III Bladder outside of introitus with straining Gr IV Bladder outside of introitus at rest VCUG grade: GrI: Just below inferior ramus Gr II: 2-5 cm below inferior ramus Gr III: Outside introitus and exterior

16 Cystocele

17 Cystocele Central defect: 5-15%, result from attenuation of the levator hiatus fascia Lateral defect: 70-80%, disruption of lateral attachments to vesicopelvic or pelvic side wall Combined central and lateral defects

18 Symptomatology of Anterior Vaginal prolapse
Gr I and Gr 2 cystocele: asymptomatic or stress urinary incontinence Gr III and Gr IV cystocele: vaginal mass, lower abdominal fullness, frequency urgency, stress urinary incontinence, dysuria, leaning forward to void, residual urine sensation, frequent cystitis, dyspareunia, ureteral obstruction

19 Physical examination of vaginal prolapse
Pelvic examination in supine and standing position Evaluate concomitant types of prolapse: rectocele and uterine prolapse Ask the patient to strain and relax with blade retraction of rectum or finger pushing the cervix upward Reduce cystocele to test stress incontinence

20 Differential diagnosis of cystocele
Urethral diverticulum Ectopic ureterocele Cystourethrgraphy identified descent of bladder base and evaluate the urethrovesical angle MRI: diagnosis of cystocele with or without combination of enterocele or rectocele

21 Cystourethrography of Cystocele

22 Urodynamic study Multichannel pressure flow study:evaluate detrusor dysfunction, stress urinary incontinence, and voiding efficiency Provocative maneuvers: coughing, walking, jumping, straining to demonstrate SUI Detecting detrusor overactivity in patients with symptom of urge incontinence Residual urine volume determination

23 Uterine prolapse and cystocele causing bladder outlet obstruction

24 Reduction of prolapse relieves BOO in patient with SUI

25 Cystocele and Stress urinary incontinence
High grade cystocele masks intrinsic sphincteric deficiency in 50-80% women Correction of cystocele without concomitant anti-incontinence surgery may unmask ISD and cause SUI Use of pessary test or vaginal pack for prolapse reduction and detecting genuine stress urinary incontinence

26 Cystourethroscopy and Lower urinary tract ultrasound
Examination of bladder and urethral pathology, such as stone, tumor, stricture Bladder neck incompetence and intrinsic sphincter deficiency should be suspected Measurement of striated urethral sphincter component and bladder neck hypermobility by transrectal sonography of bladder & urethra

27 Female Urethral Incompetence
Bladder neck incompetence Urethral incompetence

28 Urethral Ultrasound in ISD and Cystocele

29 Surgical procedure for cystocele
Gr I: observation in asymptomatic women or bladder neck suspension when treating SUI High grade cystocele with SUI: anterior colporrhaphy with pubovaginal sling Correct uterine prolapse or rectocele concomitantly to prevent exacerbation of vaginal prolapse after colporrhaphy

30 Techniques of cystocele repair
Raz 4 corner suspension Vaginal sling procedure Pubovaginal sling procedure with colporrhaphy Fascial patch repair to levator ani muscles and vaginal cuff or pubocervical fascia Burch colposuspension

31 Technique of Anterior colporrhaphy

32 Urodynamic point-of-view in cystocele repair
Correct cystocele with adequate increased urethral resistance but not obstructing bladder outlet Patient with large cystocele may have detrusor underactivity and void by abdominal straining Accurate assessment of detrusor and urethral function during urodynamic study

33 Detrusor underactivity in Cystocele

34 Complications of cystocele repair
Bladder injury during vaginal wall dissection Ureteral injury during placing plication sutures Urethral injury during dissection or suture passage Infection and fascia rejection Ureteral obstruction Stress urinary incontinence becomes prominent after cystocele repair

35 Postoperative Care Foley catheter and vaginal pack removed at day 1 or 2 Check residual urine after voiding till volume is less than 100ml Keep on antibiotics for 3 weeks to prevent synthetic material infection or abscess Laxatives and avoid abdominal straining

36 Postoperative urinary incontinence
Intrinsic sphincteric deficiency is unmasked after cystocele correction De novo detrusor overactivity Urethral kinking due to improper placement of pubovaginal sling Videourodynamic study and transrectal sonography are indicated and a second sling can be applied at distal urethra for ISD Urethrolysis to relieve urethral obstruction

37 Transrectal sonography of ISD after repair of cystocele

38 Apical Vaginal prolapse (Enterocele)
Peritoneal herniation at vaginal apex Sometimes difficult to differentiate from large cystocele or high rectocele Acquired enterocele (5-27%) after Burch culposuspension and leave a wide open cul-de-sac, or after hysterectomy and a weakened vaginal apex Can be prevented during pelvic surgery

39 Apical Enterocele

40 Symptomatology of Enterocele
Mass at or beyond introitus Perineal pressure, vaginal mucosal erosion Mass will reduce spontaneously at supine

41 Physical examination of Enterocele
Examined in supine and standing positions Ask patient to cough and strain, with finger or blade retraction of bladder or rectum Posterior vaginal wall length is normal in enterocele,but shortened in vault prolapse Check rectocele to find the presence of apical vaginal prolapse

42 Physical examination of Vaginal Cuff Prolapse

43 Treatment of Enterocele
High peritonealization and approximation of uterosacral ligaments, obliteration of hernial sac and cul-de-sac When vaginal ulceration, vaginal surgery, or pelvic prolapse surgery is planned Abdominal approach or transvaginal approach is feasible

44 Transabdominal repair of Enterocele

45 Transvaginal Repair of Enterocele
More direct and less morbid All component of vaginal prolapse should be repaired concomitantly Dyspareunia due to vaginal shortening should be addressed Approximation of levator ani at posterior vaginal wall can preserve vaginal depth

46 Transvaginal repair of Enterocele

47 Complication of Enterocele repair
Small intestine injury – adhesion of small bowel after previous pelvic surgery or irradiation Rectal injury – careful vaginal wall dissection can prevent it Bladder perforation – in combined cystocele with enterocele Ureteral injury – during applying purse-string suture at herniac sac

48 Vaginal vault prolapse
Due to vaginal apex weakness after previous hysterectomy Patients often have sensation of mass protruding from vagina Perineal pressure Dyspareunia Difficult urination and vaginal reduction to facilitate voiding

49 Pelvic examination of Vault Prolapse
Posterior vaginal wall foreshortening Careful differential diagnosis from enterocele, surgical procedure is similar Nonsurgical procedure – a pessary Urodynamic study to investigate detrusor function and stress urinary incontinence

50 Pessary

51 BL vagina rectum

52 bl cx r USL

53 Uterosacral Ligament

54 AC Richardson: Breaks, not attenuation or stretching
Site-specific defects Clin Obstet Gynecol 1993; J Pelvic Surg 1995



57 Surgical procedures for Vaginal Vault Prolapse
Abdominal sacraocolpopexy – securing vaginal vault to sacrum using autologous, allogenic,or synthetic material to bridge the gap Transvaginal levator myorrhaphy – high approximation of levator uterosacral ligament complex at midline Sacrospinous ligament fixation Colpocleisis – closure of vagina in sexually inactive women

58 Transabdominal Sacrocolpopexy

59 Transvaginal Levator myorrhaphy

60 Sacrospinous fixation

61 Uterosacral ligament suspension

62 Uterosacral ligament suspension

63 Uterine prolapse Perineal pressure Dyspareunia Mass at introitus
Urinary incontinence Difficult urination Constipation

64 Examination of uterine prolapse
Evaluated in supine and standing position Voiding cystourethrography for cystocele and urethrovesical angle MRI to detect concomitant enterocele or rectocele Urodynamic study in supine (after reduction) and sitting position for voiding function and presence of ISD

65 Uterine prolapse

66 Surgical treatment Abdominal or vaginal hysterectomy with apical vaginal fixation to prevent postoperative vaginal vault prolapse Transvaginal levator myorrhaphy Repair other component of pelvic prolapse including cystocele, enterocele, rectocele by myorrhaphy or synthetic mesh or cadaveric fascia

67 Posterior vaginal wall prolapse
Rectocele results from a weakened rectovaginal septum and perineal body Stool becoming stuck during defecation Chronic constipation Perineal pressure Backache Fecal incontinence

68 Rectocele

69 Grading of Rectocele Gr I (A) Protrusion with straining
(B) Protrusion does not reach introitus Gr II Protrusion to introitus Gr III Protrusion outside introitus

70 Surgical repair of Rectocele
To restore rectovaginal septum and perineal body Risk of rectal injury and dyspareunia secondary to vaginal tightening Repair the transverse perineal muscles by sutures at superficial and deep perineal muscles Not to close vagina too tightly

71 Technique of Rectocele repair


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